Eight decades of the Yale System

Ever since its implementation in the 1920s, the Yale System of medical education has been the point of common reference for alumni of the School of Medicine. Ralph I. Horwitz, M.D., chair of the Department of Internal Medicine, touched on its enduring qualities when he addressed faculty recently about the education-review process now under way. “I have not been able to find two people able to agree on exactly what the Yale System is, but there is a strong consensus on the essentials,” he said. It’s an approach to learning that is self-directed and collaborative, rather than competitive. The environment is that of a graduate school. Examinations are for self-assessment, not for grades or class ranking. Learning takes place in small groups rather than in large lectures. And the curriculum should allow free time for reading, independent research and reflection.Alumni have their own memories of how the Yale System shaped their careers in medicine. As the medical school takes an exceptionally thorough look at both how and what it teaches—all in the context of renewing the Yale System—we invited alumni to reminisce about what it meant to them. Their recollections follow.

A conversation that resounded during four decades of practice

Morris A. Wessel, M.D. ’43My most striking memory as a medical student from 1939 to 1943 is of the availability of faculty members when a student sought help. As a third-year student, I was frustrated at my inability to comfort an 8-year-old child in a cast with a fractured femur.

I went to Dr. Edith Jackson in the pediatrics department, who was interested in children’s behavior during hospitalization and had returned recently from a six-year leave of absence spent in Vienna obtaining psychoanalytic training. I remember her warm greeting as I entered her office. I shared my frustration about my patient—and remember suddenly describing bitter memories of my own tonsillectomy at the age of 8!

Dr. Jackson showed me the Anna Freud-Dorothy Burlingham studies describing the behavior of children evacuated to the countryside from war-torn London. She offered to meet with me periodically to discuss these reports and my concerns about patients.

These discussions led me to comprehend infant and child behavior in normal and stressful times. I applied this knowledge during every patient contact in my four decades of pediatric practice in New Haven. I appreciate having been introduced to this explanation of children’s behavior in my discussion with Dr. Jackson 58 years ago in the Department of Pediatrics.

Wessel cared for generations of New Haven children as a pediatrician in practice from 1951 until his retirement in 1993.

Proximity was everything for a once-shy student

Richard W. Breck, M.D. ’45M
The Yale System meant everything to this lecture-hall introvert. The WWII years of 1942-45 provided an exciting background in which to study medicine. The small-group instruction, either bedside or seminar, was the best part of the system for me. On rounds, standing inches from Drs. Blake, Peters, Powers, Geiger, Blumer and Tileston, I was in their debt; somehow, a bit of their intellectual dandruff fell on me and stuck.

I didn’t know the words “role model” then, but Francis Blake was, to me, the clinician I wanted most to emulate. I have been guided many times since graduating 54 years ago by thinking, “What would Dean Blake have done in a situation like this?”

I also “mourned” the passing of the smaller classes—I think 100 is too large for YSM.

Breck, a long-time participant in alumni affairs and former secretary of the AYAM Executive Committee, retired from general practice in 1995. He lives in Wallingford, Conn., where he sees geriatric patients on a part-time basis.

‘They treated us as responsible adults’

Laura White Neville, M.D. ’46The one major facet of Yale’s approach to medical education that impressed me was the way they treated us as responsible adults. We were told in the first week that we had all been selected with the confidence that we would all graduate. We were told that we were capable of studying on our own, taking only those tests we wished to take, except for Parts I, II and III of the national boards. The faculty would be available for counsel and for whatever help we thought necessary, and without outside pressure.

I can still visualize our neuroanatomy professor as he stood at the blackboard, chalking an outline of the brain, using both hands to draw the left and right sides of the brain simultaneously. He turned to us and said, “Ladies and gentlemen, you are now members of a learned profession, and you will be students for the rest of your lives.”

Neville was in private practice in pediatrics and psychiatry for many years in Syracuse, N.Y., where she served on the clinical faculty of the SUNY Health Sciences Center. She and her husband, John F. Neville Jr., M.D. ’46, are retired and living in Cotuit, Mass.

A true university approach that fostered independence

Olive E. Pitkin, M.D. ’47Coming from a small-town high school in which most of what I learned was outside of school hours, and from Bennington College, which left its students pretty much on their own as well, I found the Yale System entirely congenial. We were offered the best of lectures, but as I became aware that I learned little from material I only heard, and that no one seemed to mind if I stayed away and concentrated on what was in the books, I was able to study in my own way with a clear conscience. In the clinical years we saw superlative physicians in action, and my images of most of them, more than 50 years later, are so vivid and still so admirable that I think we must have been given very generous exposure to these splendid role models. From them I really did learn what it means to be a good doctor. These experiences I did not stay away from; such apprenticeship can only be achieved by personal contact with a master.

If by the Yale System it is meant this true university approach—treating the students as adults who are there to learn, making available to them the ingredients of a superb professional training, allowing them to take it in at their own pace and with techniques of their own devising—then it worked for me. My medical education has been, ever since, a matter for both gratitude and pride.

Pitkin retired in 1984 from the New York City Department of Health, where she was assistant commissioner for maternal and child health services. She lives in Westerly, R.I.

Another view of the thesis requirement

David E. Morton, M.D. ’48, HS ’55Having been a medical student, instructor in anatomy, and house officer at the School of Medicine in the 1940s and ’50s, I had considerable experience with the thesis requirement. I also received the Keese prize for the best thesis in 1948.

Although times have changed, I concluded when I left the School of Medicine that the thesis requirement should be dropped except for those taking the combined M.D. and Ph.D. programs. My reasoning was that the thesis was truly useful only for those students planning to enter academic medicine and research. And in my day only 5 to 10 percent of the class did so. I then felt that the considerable amount of time spent on the thesis would be better spent in the study of medicine. The volume of knowledge at that time seemed so great to cover in four years without spending time on a thesis, and think how much greater it is now!

Morton, who retired from private practice in internal medicine in 1993, lives in Pueblo, Colo.

A good place to be in the turbulent 1960s

Ralph Falkenstein, M.D. ’69Historians have described the decade of the 1960s as one of turbulence and upheaval among America’s youth. Beyond the cauldron of student protests, the Vietnam War and drug experimentation, there was a haven where those fortunate enough to gain admission to the Yale School of Medicine could achieve their goal of obtaining the finest education under the relatively tranquil canopy of the Yale System.

As a member of the Class of 1969, I remain appreciative of Yale’s approach of allowing students latitude in balancing their interests and scientific pursuits with personal responsibility for absorbing course work through the guidance of concerned mentors who impart their knowledge and skills in a non-intimidating fashion. We were, at a rather tender age and with limited medical familiarity, considered responsible individuals, whose desire for learning was nurtured as thoughtfully as our hopes for developing into worthy physicians. In short, a dignified way to study a noble profession and a stark contrast to much of what was going on in the medical and nonmedical world around us.

Falkenstein is an ophthalmologist in Danbury, Conn.

‘An ideal education’ that emphasized responsibility

Mary Lake Polan, M.D. ’75, Ph.D. ’70As someone brought up in the 1960s, the Yale System was a natural and very comfortable extension of the ’60s sense of freedom and exploration. I graduated from Yale School of Medicine in 1975, having received my Ph.D. from Yale in molecular biophysics and biochemistry five years earlier. At the time I was in medical school, there were no grades and to graduate only required passing the boards and submitting a thesis. The system allowed me, during my first year of medical school, to continue working in a laboratory in the biology department, where I had been a postdoctoral fellow. I was paying for my education and Yale gave me the ability to learn and to structure that education in a way that was best for me.

Because I had a Ph.D. and did not need to submit a thesis, the Yale System allowed me to read a book on pharmacology and take Part I of the boards before my class actually had the pharmacology course. Passing the boards that first year meant I could finish medical school in three years. I wanted to learn about how medicine was practiced in other countries and the Yale System allowed me to spend both my pediatric and obstetrics and gynecology rotations at Oxford.

The Yale System stressed freedom of choice in how you could educate yourself and along with that went the personal responsibility for doing it. My experience at Yale was that everyone in both the medical school and the graduate school was available to help with research, information, advice and mentoring. All you had to do was ask. It was an ideal education that taught not just the particulars of medicine, but allowed one to live through the process of real-life decision-making and responsibility—probably the very best preparation for a career in medicine.

Polan is chair of the Department of Gynecology and Obstetrics at Stanford.

A chance to be self-motivated and rewarded with knowledge

Thomas J. Smith, M.D. ’78The Yale System is why I came to Yale in 1974 and spent $10,000 a year more than to go to Ohio State. The flexibility of a fifth year, which happened to be free, was also a major draw.

The Yale System offered an opportunity to be self-motivated and rewarded with new knowledge (whatever its relevance) rather then punished for not knowing the answer to multiple-choice questions. The skills I honed during my time at Yale—going to the library, asking questions, not being satisfied until I knew the material and the relevant answers—have served me well in my practice and academic careers.

In addition, the thought that “Well, now I know it all and can stop studying” never crossed our minds.

As we move into a system that can track medical outcomes, and compare us one to another based on our outcomes, adherence to “best medical practice” and the subsequent good medical results will become increasingly important. Since medical care advances, the only ones who will be able to keep up are those with a “Yale System” approach of adult, life-long learning.

Smith is an associate professor of medicine and health administration at the Medical College of Virginia/Virginia Commonwealth University in Richmond.

Tools to deal with a world of ambiguity

Joann Bodurtha, M.D. ’79, M.P.H. ’79What did the Yale System mean to me? It enabled me to get a firm foundation for life-long learning and adaptation to uncertainty. It gave us the freedom to take the time to understand something as well as it was currently understood with thoughtful teachers, small group discussion, and no preoccupation with “what’s on the test?” The memorable moments and experiences—announcement of the Nobel Prize in class, the chaplain in anatomy, a women-in-medicine lectureship, the thesis, a certain bike-riding dean’s report of prostate discomfort, and many others—continue to provide ingredients for my current clinical care and teaching.

Much of my happiness as a physician is due to the ongoing push to integrate all that medicine presents, from “marketing” public health to explaining molecular testing to a family. My Yale teachers inspired me to try to do my best with humor and caring and to learn from my mistakes.

Bodurtha is an associate professor of human genetics, pediatrics and obstetrics/gynecology at the Medical College of Virginia/Virginia Commonwealth University in Richmond.

The Yale System personified

Brian B. Adams, M.D. ’95One can sum up the strength of the Yale System and the essential threads of Yale’s approach to medical education in two resounding words—Dr. Gifford.

Adams is an assistant professor of dermatology at the University of Cincinnati School of Medicine and director of dermatology at the Veterans Hospital Medical Center in Cincinnati.YM